postnatal depression, maternal-infant bonding and social ......afolabi, o., bunce, l., lusher, j....

Postnatal depression, maternal-infant bonding and social support: A cross-cultural

comparison of Nigerian and British mothers.

Afolabi, O., Bunce, L., Lusher, J. & Banbury, S.

To appear in: Journal of Mental Health, 2017

Abstract

Objectives: The high prevalence of Post-Natal Depression (PND) in low and lower-middle

income countries of Africa raises questions about the functionality of the abundant informal

support accessed in the enmeshed family structure. This study examined the interaction

between social support, parity and culture in the development of PND and Maternal Infant

Bonding (MIB) among Nigerian, British and Nigerian Immigrant mothers in the UK.

Methods: Participants (N=124) were recruited from the UK and Nigeria via local support

groups for mothers, websites offering motherhood-related content and social media.

Questionnaires including the Edinburgh Postnatal Depression scale (EPDS), Postpartum

Bonding Questionnaire and Norbeck's Social Support Questionnaire were uploaded onto

SurveyMonkey®.

Results: Findings revealed significant cultural differences in PND and social support.

Multiple Regression analyses revealed that PND, social support and culture could predict

Maternal Infant Bonding (MIB), with PND being the only significant independent predictor.

Conclusions: Our findings highlight the importance that cultural factors play in the

development of PND and the establishment of MIB in the context of culturally attuned

healthcare services.

2 Postnatal Depression

Introduction

The processes and life events surrounding the perinatal period presents increased risk

for psychiatric disorders including Antenatal Depression (AND), Postnatal Depression (PND)

and perinatal anxiety (Stewart, Robertson, Dennis, Grace, & Wallington, 2003; Cantwell &

Smith, 2009). The DSM-5 describes PND as a 'major depressive disorder with peripartum

onset' as the most recent episode of major depression if onset of mood symptoms occurs

during pregnancy or in the four weeks following delivery (American Psychiatric Association

(APA), 2013).

The global prevalence rates of PND range between 10% and 15% (Pearlstein,

Howard, Salisbury, & Zlotnick, 2009; Sawyer, Ayers, & Smith, 2010; Fisher et al., 2012).

This variation may be due to the inconsistencies in the methods of screening, the diagnostic

criteria employed and the timing of assessment (Williamson & McCutcheon, 2004; Heh,

2003). Researchers have argued that PND remains under-diagnosed and under-treated

(Stewart et al., 2003; Halbreich & Karkun, 2006; Pearlstein et al., 2009). In the developing

countries of Africa, this under-diagnosis is worsened by the structure of maternity service

delivery settings and prioritised concentration on life-threatening preventable complications

of birth (Fisher et al., 2012). Further, the idealised social norm of motherhood and deference

for the good mother identity may cause symptomatic mothers to feel guilty and embarrassed

about their condition and therefore under-report their symptoms when assessed for PND


(Tammentie, Tarkka, Astedt-kurki, Paavilainen, & Laippala, 2004; Williamson &

McCutcheon, 2004; Pearlstein et al., 2009; Jones, Jomeen, & Hayter, 2014). This trend can

pose extensive risks to the mother, baby and the entire family (NICE, 2007) as the depressed

mother shows flat affect, low stimulation and general social unresponsiveness (Burke, 2003;

Field, 2010).

Previous UK based studies have reported an increased risk of PND among mothers

from ethnic minority backgrounds (Onozawa, Kumar, Adams, Doré, & GIover, 2003). These

women tend to be migrants faced with stressors related to immigration status problems,

discrimination and acculturation issues (Surkan, Peterson, Hughes, & Gottlieb, 2006). Key

cultural issues such as isolation and language difficulties have been reported among South

Asian, British Pakistani, Bangladeshi and Chinese migrant mothers in the UK experiencing

PND (Parvin, Jones, & Hull, 2004; Husain et al., 2012; Lam, Wittkowski & Fox,

2012; Wittkowski, Gardner, Bunton, & Edge, 2014; Gardner, Bunton, Edge, & Wittkowski,

2014). Ethnicity has been described as a significant predictor of depressed mood while

controlling for age, marital status, income and educational level, and infant health outcome

(Segre, O'Hara, & Losch, 2006).

Gardner et al. (2014) conducted an interpretative phenomenological analysis of the

experience of postnatal depression among six West African mothers in the UK. Five

superordinate themes were identified and included conceptualising PND, isolation, loss of

identity, issues of trust and relationships as a protective factor. Gardner et al. (2014)

explained that although women exhibited symptoms of PND, they did not regard it as an

illness but attributed it to social stress. Further, women perceived the supportive nature of

social networks as being unavailable; highlighting the role that social support plays in the

development of PND.


PND can trigger long-term negative and damaging effects that can majorly affect the

baby (Williamson & McCutcheon, 2004; Murray, Halligan, & Cooper, 2009; Parsons,

Young, Rochat, Kringelbach, & Stein, 2012). Depressed mothers may experience a mixture

of emotions ranging from apathy to anger and total rejection of the care of their babies

(Kitamura, Ohashi, Kita, Haruna, & Kubo, 2013). Empirical evidence suggest that this

undermines early childhood interactions between mother and child (e.g. Burke, 2003;

McMahon, Barnett, Kowalenko, & Tennant, 2005; 2006; Field, 2010) and can lead to

maternal-infant bonding (MIB) failure, which constitutes risk for development of social

difficulties and psychological problems later in life (Campbell et al., 2004; McMahon et al.,

2006).

Alongside PND, Maternal-Infant relationship Dysfunction (MID) is becoming an

increasingly recognised mental health issue in obstetrics and gynaecology (Brockington,

2004a; Kitamura et al., 2013). Maternal Infant Bonding (MIB) is the care-giver-to-infant

direction of the mutual and reciprocal systems of interaction in the attachment process which

begins at birth, grows and endures over time (e.g. Bowlby, 1969; Klaus & Kennell, 1976;

Edhborg, Nasreen, & Kabir, 2011). However, because the aetiology of MIB failure is only

minimally investigated (Kitamura et al., 2013), there are still reservations among researchers

about the role PND plays in the development of MIB. Some argue that both issues are

separate and merely coexist (Brockington, 2004b; Kitamura, et al., 2013). In a study of 1,198

rural Japanese mothers, Kitamura, et al. (2013) reported that depressive mood and bonding

failure did not predict each other, but predicted abusive parenting. This infers that other

variables including cultural factors may be involved in the establishment of MIB among

depressed mothers.

Previous studies have consistently identified an inverse relationship between social

support and development of PND (Heh, 2003; Surkan et al., 2006; Leahy-Warren &


McCarthy, 2007; MacArthur, Winter, & Bick, 2007; Dennis & Kingston, 2008). However,

the estimation of the protective importance of social support against development of PND

and ultimately the establishment of MIB is potentially questionable. Goodman (2008)

identified social support as a factor that can impede maternal-infant interaction and ultimately

bonding. In a study of adolescent mothers, Logsdon, Birkimer, Simpson & Looney (2005)

explained that receiving 'too much' support can be damaging, especially when the support

does not match the desire of the recipient. This is because culturally driven practices which

take over rather than support mothers to care for their babies may hinder the quantity and

quality of interactions between mother and child, possibly impacting on self-efficacy

(Salonen et al., 2009), and potentially leading to depression (Crockenberg & Leerkes, 2003).

Therefore, some types of social support offered to mothers may not ultimately constitute the

right support while some supportive structures may not necessarily be beneficial for all

women and could in fact be counter-productive (Jones et al., 2014; Lindblad-Goldberg &

Dukes, 1985). Therefore, there is a need to examine the level of meaningfulness of the

support provided by the social network, especially in mothers with PND and trans-cultural

variations in the contributions of social support to development of PND.

The current study explored the relationship between PND, social support and MIB

cross-culturally. We hypothesised that between Nigerian, African Immigrant and Indigenous

British mothers, there would be no variation in social support, PND and MIB.

Method

Participants

124 Participants were recruited from the UK (n=79) and Nigeria (n=32) through

online Pre- and Post-natal Depression and Support (PANDAS) groups in London, UK.

African immigrants (n=13) were Nigerians who had immigrated to Britain. The mean


duration spent in Britain among the African Immigrant group was 12.23±10 years. Mothers

who delivered no later than two years prior to the time of the study; who had no previous

history of other types of depression or mental health problems and who can communicate

(read, speak, listen and write) English language were included in the study. The criteria

specified mothers must have delivered two years prior to the time of the study because

Maternal-infant bonding was also been tested as a variable in the study. In addition, it is

important to track persistence of the condition beyond one year especially in undiagnosed or

poorly diagnosed and untreated individuals which made up the bulk of the Nigerian

participants. Some authors have reported case studies and cohorts of women suffering PND

up to four years after birth (Woolhouse, Gartland, Mensah, Giallo & Brown, 2016; Sutter-

Dallaya, Cosnefroyb, Glatigny-Dallaya, Verdoux & Rascle, 2012). Evidence have also

suggested higher prevalence of depressive symptoms at four years postpartum than at any

period during the first year postpartum (Woolhouse, Gartland, Mensah, Brown, 2015). The

participants were also instructed and encouraged to recall how they felt during weeks

following their delivery while responding to the survey.

Measures

Questions were asked using SurveyMonkey® about age, sex of last child, marital

status, number of deliveries, history of obstetric complications during last pregnancy and

delivery, ethnicity (nationality) and available baby-care assistance. PND screening was

conducted using the standardised Edinburgh Postnatal Depression Scale (EPDS; Cox,

Holden, & Sagovsky, 1987). This is a 10-item questionnaire with a four point Likert scale.

Responses on Questions were scored 0-4, with the highest obtainable score being 30 and

scores above 12 indicating PND. The Cronbach alpha for this study was 0.71. The Impaired

bonding subscale of the Postpartum Bonding Questionnaire (PBQ; Brockington, Fraser, &

Wilson, 2006) was used to assess MIB. The PBQ consists of a series of 25 statements,


followed by a six-point Likert scale ranging from Always to Never. A score above 12

indicates defective bonding and lower scores indicate good bonding. The PBQ also has good

validity 0.69 [Cronbach alpha 0.76 reported by Brockington et al. (2006)]. Total functional

social support and total support network available to the mothers during postnatal period

were measured using Norbeck Social Support Questionnaire (NSSQ; Norbeck, Lindsey, &

Carrieri, 1981; 1982; Norbeck, 1995). NSSQ also measures two sub-themes of support;

emotional support and tangible support (Aid). Total Functional support was the sum of the

emotional and tangible support scores. The NSSQ was adapted for the study by adding child-

care related words or phrases to make it more situation-specific. NSSQ has a reliability

coefficient estimated as 0.68 (Stevens, 2008). The Cronbach alpha for this study was 0.71.

Procedure

Ethical clearance was granted by the University Psychology Research Ethics

Committee. The information sheet, consent form, questionnaires and a debrief form were

uploaded on Survey Monkey. Permission to mention the study was sought via administrators

of websites and Blogs offering motherhood-related contents (such as mumsnet.com,

netmums.com, mums-aid.org helpforbusymums.com) and social media (Facebook and

Twitter). Then, survey link was advertised on the websites and blogs. Participants based in

Nigeria were recruited through advertisements on social media and blogs offering

motherhood-related contents (mumsinnigeria.com and mamalette.com). A survey link was

sent to the coordinators of PANDAS for distribution to potential participants who met the

inclusion criteria for the study. 159 mothers started the online survey, of which 124 (78%)

completed all questionnaires. Data was obtained from respondents who consented to take part

in the study and responses were downloaded from SurveyMonkey® for analyses. With

reference to table 1 below, the mean age of respondents was highest (30.85±6.35) among

African Immigrant mothers, 28.28±4.40 for Nigerian mothers and 29.66±5.36 among British


mothers. The majority (77%) of the African Immigrants were primiparous. The same trend is

observed in Nigerian mothers (63%), the majority (66%) of British mothers were

multiparous.

Results

As can be seen in Table 1., the African immigrant sample rated the delivery and

postnatal support received from healthcare professionals in the UK as being moderate to a

great deal of support whereas about one-third of British mothers rated the support as ranging

from none-at-all to just a little.

*Insert table 1 about here*

The majority of British (72%) and African Immigrant (77%) mothers had EPDS

scores above 12 (15.16±9.109 and 14.23±6.821 respectively), however, only 19% of Nigerian

mothers did (9.03±4.73). Maternal Infant Bonding scores were significantly different

between African Immigrant, Nigerian and British mothers, Χ(2,N=124)2 =17.55, ρ<0.05, with

African Immigrant mothers having the highest mean PBQ score (16.08±12.26) and Nigerian

mothers having the lowest (6.58±3.97). Nigerian mothers reported the highest level of

Emotional Support (56.90±28.84), Tangible Support (AID) (27.70±15.86) and Total

Functional Support (84.59±43.61). British mothers reported the highest social network

ratings (43.69±35.85) and African Immigrants had the lowest scores on all parameters.

We found a statistically significant difference in EPDS scores based on the interaction

of Total functional support received, parity and the cultural (nationality) grouping, Ϝ(1, 113)=


5.099, ρ<0.05, partial η2=0.02. Further, we found a significant main effect of cultural

affiliation (African Immigrant, Nigerian or British) on PND Ϝ(2, 113)= 5.037, ρ>0.05, partial

η2=0.08. However, although table 2 shows that women scoring above the 50th percentile on

total functional support had slightly higher mean PND scores (11.23±6.14) than those below

the 50th percentile (11.09±7.55), the main effect of Total Functional Support score was not

significant, Ϝ(1, 113)= 0.001, ρ>0.05, partial η2=0.00. In addition, although multiparous mothers

had higher mean PND scores (11.26±6.9) than primiparous mothers (11.07±6.9), this

difference did not reach statistical significance, Ϝ(1, 113)= 3.70, ρ>0.05, partial η2=0.032. The

nationality x total functional support interaction was significant, Ϝ(2, 113)= 6.560, ρ<0.05,

partial η2=0.104, as was the nationality x parity interaction, Ϝ(2, 113)= 11.286, ρ<0.05, partial

η2=0.166.

*Insert table 2 about here*

Further analyses using multiple linear regression to predict MIB (PBQ scores)

generated a significant model, F(6,117) = 34.784, ρ<0.01. This model explained 62% of the

variability in PBQ scores (Adjusted R2 =0.622). Table 3 shows a 1% increase in amount of

Emotional support and Tangible support causes a 2% and 0.4% decrease in PBQ scores

respectively while holding other variables constant. In addition, the model non-significantly

predicts that British mothers will have 9% lesser PBQ scores than Nigerian mothers, t=-

1.495, β=0.089, ρ>0.05 while African Immigrants will have 3% higher PBQ scores, t=0.525,

β=0.033, ρ>0.05, holding all other variables constant. Individually, Total functional support

has the highest effect on PBQ with a 1% increase in TFS resulting in 2% increase in PBQ

scores. However, the effect was not statistically significant, t=1.13, β=2.151, ρ<0.01. PND


was the only statistically significant independent predictor of MIB, t=13.316, β=0.766,

ρ<0.01, with a 1% rise in EPDS score giving rise to a 1% rise in PBQ scores.

*Insert table 3 about here

Discussion

This study examined social support, parity, postnatal depression and maternal infant

bonding cross-culturally among Nigerian, African immigrant and British mothers. We found

a significant positive correlation between Total functional support (TFS) and Total social

network (TSN) in all categories (Nigerian, African immigrant and British mothers). However,

our findings revealed that British mothers received significantly higher total functional

support when compared to Nigerian and African immigrant mothers. Further differences were

apparent between the Nigerian and African Immigrant TFS scores, where lower TFS scores

were observed among African Immigrant mothers. These differences may be due to the size

of the social network available to Nigerian mothers rather than the actual functionality of the

support from the network. This may be reflected in the variability in total functional support

attributable to total social network which was highest among British mothers compared to

African immigrants and Nigerian mothers. Compared to African immigrant and Nigerian

mothers, British mothers had better access to formal social support networks (e.g.

community-based peer support groups, health visitors and psychological wellbeing

practitioners) which are more evidence-based in their functionality and contributions. African

Immigrants are faced with other issues of immigration status, acculturation, discrimination

and stereotyping which limits their social network and functional support received from


formal supportive structures (Onozawa et al., 2003; Surkan et al., 2006). This implies

existence of other factors accounting for the improved total functional support not accounted

for in the model. Jones et al. (2014) suggested that some types of support received from the

social network especially family network may not ultimately constitute the right support

while some supportive structures may not necessarily be beneficial for all women. This

demonstrates that there is need for the consideration of person-centred care principles and

other aspects of individuality in making social support functional.

The findings highlight statistically significant difference in PND based on the

interaction of Total functional support received, parity and the nationality. Findings also

showed that only nationality classification has a significant main effect on PND, while parity

and total functional support did not. This suggests that cultural variations as a result of

different nationalities tend to mediate the effect of parity and social support on PND, a

finding consistent with the assertions that culture is the milieu for all affective experiences

(Bashiri & Spielvogel, 1999). The significant PND difference between groups may not mean

that prevalence of PND is different between the two countries, as empirical evidence has

shown PND prevalence rates (15%-19%) in Nigeria (Adewuya, Eeguranti, & Lawal, 2005;

Abiodun, 2006) to be comparable to global figures. However, the acknowledgement of the

symptoms and the manner of expression of the symptoms in the two cultures has been shown

to be different; Nigerians somatisize symptoms of depression (Bashiri & Spielvogel, 1999;

Adewuya et al., 2005) and may be more reticent than Britons in acknowledging it when

completing surveys. African immigrants may also have embraced the expressive

characteristics of their environment due to acculturation (their mean length of stay in Britain

was approximately 10 years). Generally, the differences between the three groups may not

necessarily reflect differences based on cultural factors and practices but structural and

functional disparities in societal settings. These findings are similar to Shaw, Levitt, Wong,


Kaczorowski, and Group (2006) who revealed that neither home visitation nor peer support

reduced EPDS scores for mothers, but scores significantly reduced only in mothers at risk for

PND (Shaw et al., 2006).

There was dissimilarity with previous cross-cultural study in this regard. A study

between Taiwan and UK participants found no statistically significant difference in

prevalence of PND between the two cultures (Huang & Mathers, 2001) despite the significant

differences in culturally-based postnatal social support. It must be noted that the current study

also recruited participants via local support groups for postnatal depression. This could have

significantly contributed to the percentage of British mothers in the study having high PND

scores. Our findings conflict earlier research (Leahy-Warren & McCarthy, 2007), with higher

PND scores being found among mothers who had total functional support above the 50th

percentile. Additionally, Leahy-Warren, McCarthy, and Corcoran (2011) found a graded and

significant relationship between total functional social support and PND at six weeks

postpartum, reporting that first-time mothers receiving medium and low levels of emotional

support had five and eight times higher risk of PND, respectively. Surkan et al. (2006) did

not find evidence that the influence of social support and social network on depression varied

by race. Although, their study was conducted in the United States (US), and apparently

differs from UK in population characteristics. Stewart et al. (2003) also reported that no

relationship was found for ethnicity, age, education and parity but did not document the effect

of the interaction of these variables.

The study found the interaction of social support, culture and PND significantly

predicts maternal infant bonding. Our results showed that increased emotional support and

tangible support is significantly associated with poor MIB in Nigerian mothers. This was not

the case in British mothers and African immigrants where increase in emotional and tangible

support showed improved MIB. Reasons for this finding are unclear because maternal-infant


bonding assessment from Nigerian mothers was highest among the three cultural categories.

However, it is vital to observe that the major source of social support in the enmeshed family

structure found among Nigerians consists of family members (Osamor, Owumi, & Dipeolu,

2015). This means, except in cases of delivery complications and routine immunisation visits,

newly delivered mothers rarely have contacts with or support from any form of health

professional after delivery. While this finding is an association which does not indicate

causality, it portends the possibility that the form and means of social support received by

Nigerian mothers could be hindering adequate maternal infant bonding. Yet, it does not mean

that family members are not supportive; but their understanding and provision of support may

be defective and potentially harmful to the quality and quantity of interactions between

mother and child that is needed to establish adequate bonding. Indeed, Goodman (2008)

noted social support as a factor that can impede maternal-infant interaction and bonding.

From the regression model, British mothers were found to be more likely to have

better MIB than Nigerian mothers; although British mothers in the study generally had poorer

maternal-infant bonding and higher average EPDS score when compared to Nigerians. This

was not statistically significant. There appears to be more clandestine variables affecting this

relationship; however, the model implies that the presence of PND might be the mediator for

some of these effects. This appears to be valid since majority of the women in the study had

PND. Notwithstanding, the strong idealistic motherhood notion intrinsic to the cultural

perspectives of Africans, including Nigerians (Jones et al., 2014) may be responsible for the

lower mean PBQ scores rather than actual strong bonding, particularly since the data was

based on self-report measures. Finally, greater exposure to formal social support networks via

the National Health Service may have helped British mothers to better understand bonding

and how to foster it.


A variety of concerns necessitates the need for caution in the interpretation of the

study findings. Factors such as parenting efficacy and parenting practices, which may

confound social support and cultural differences, were not measured. Further, the African

immigrant group was smaller than other groups. The cross-sectional design of this study also

restricts deductions about the relationships examined. There was difficulty in weighing

whether support received from the social network was dysfunctional. The social network

persons categorisation employed in the Norbeck's Social Support Questionnaire (NSSQ)

combined both immediate family members of the new mother and her in-laws in the family

or relative network person category. Such ambiguities in categorisations blur the visibility of

any existent strained relationship or other dysfunctionality in the family network and preclude

their contribution to the TFS score. Nigerian participants in the study may not have been

adequately representative of the population as they were accessed through social media and

website advertisements. An overwhelming majority of mothers in Nigeria do not have access

to internet (National Bureau of Statistics, 2012) and may have been excluded from

participating in this study. Also, the distribution means the Nigerian participants may be more

modernized and thus fail to fully reflect the traditional enmeshed family structure

characteristic of the Nigerian society.

Furthermore, the researchers used a cut-off point of 12 or more on the EPDS among

Nigerian mothers in this study as against ≥10. This was because previous recommendations

by authors suggested a threshold guideline for using the EPDS to identify PND within family

practices (a threshold score of 10) and 12 within research studies (Cox et al., 1987;

Robertson, Celasun & Stewart 2003). This suggestion was not explained based on country of

origin or culture. However, more recent studies have tended towards a general consensus for

EPDS cut-offs at 13 or more (Robertson, Celasun & Stewart, 2003; Parsons et al, 2011).

However, Tsai et al. (2013) reported a pooled sensitivity of 0.94 (95% confidence interval


[CI], 0.68-0.99) and a pooled specificity of 0.77 (95% CI, 0.59-0.88) at a cut-off score of ≥9,

with higher cut-off scores yielding greater pooled specificity at the cost of lower pooled

sensitivity (Abiodun, 2006). However, the authors reported high heterogeneity between

studies with exclusive sensitivity in some studies as high as 0.83. In addition, in Nigeria,

Adewuya, Ola, Dada and Fasoto (2007) reported that at a cut-off score of 10 on the EPDS

was found to be the best for screening for both major and minor depression (sensitivity =

0.867, specificity = 0.915) but a cut-off of 12 was found to be the most appropriate for major

depression only (sensitivity = 1.000, specificity = 0.961). As the survey was online based for

Nigerian mothers, researchers thought raising the cut-off will only identify Nigerian women

with major PND and avoid raising false alarms which could contribute as a stressor for those

with minor or no depression. The researchers also hope avoiding false positives was a more

important trade-off based on the overall methodology of the study.

However, when addressing the implications for future practice, there is a need for

practitioners to be understanding of the needs of African immigrants in the UK. This is

because findings suggest that this group have lower functional support and social network,

higher PND and poor MIB. These indices differ from both British and Nigerian categories

implying that African Immigrant mothers pose their own unique experiences and health care

needs. Therefore, culturally-sensitive care, which is only based on assumptive African

stereotypes alone may not suffice when making inclusive healthcare arrangements for them.

Further, there is need for improved structuring in formal social support networks and

community-based mental healthcare for newly delivered mothers in Nigeria as is existent in

the UK. Such structures should include improving post-delivery access to health

professionals outside the clinical setting even when there is no imminent physical problem,

since PND can go undiagnosed. This will create an opportunity for critical mental health

assessment of, at-risk, newly-delivered mothers, especially within the puerperium period.


Antenatal care in Nigeria and the UK for African immigrants may also need to incorporate

training for family members on providing supportive care which does not take-over care of

the baby (substitutive) from the mother but rather assists the mother (facilitative). There

exists a gap in research and measurement instruments for dysfunctional support within social

networks, which begs further research. Further research is also needed in giving proper

perspective to substitute and facilitative approaches within the context of tangible support for

newly delivered mothers and their contributions to PND and MIB. More cross-cultural

studies designed prospectively will aid better understanding of the relationships between

social support and different cultural factors in the development of PND.

In conclusion, culture plays a significant role in the amount of functional support that

is accessible from the social network for women with PND. British mothers are more likely

to receive functional support from their social networks than Nigerian and African Immigrant

groups. Parity and social support did not significantly influence the development of PND

individually or collectively; but their effects may be mediated by cultural or societal factors.

The development of PND appears to be affected by interaction of parity, social support and

culture. Also, the study established that the interaction of the presence of PND, culture and

social support significantly predicts strength of maternal-infant bonding, despite PND being

the only significant individual predictor. Though speculative, African immigrants

demonstrated many indices that highlighted they may be at risk of assumptive stereotypes

and discrimination, which may cause disparities in the formal and informal support and

skilled mental healthcare that they access when compared to other British mothers. Further

cross-cultural research may examine these cultural differences when working in healthcare

with African mothers.


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